Medical-Surgical Nursing Study Guide
Questions
The nurse sees in the patient's record that the patient has a Braden score of 20. Which nursing
action is the nurse most likely to perform in the care of this patient? - ANS-Continue routine
assessments
A thin, malnourished patient requires emergency abdominal surgery. After the surgery, in order
to promote wound healing, what does the nurse encourage? - ANS-High-quality protein diet
The nurse is directing the home health unlicensed assistive personnel (UAP) in the care of an
older adult patient. The patient reports dry skin and wants help in applying an emollient cream.
What does the nurse direct the UAP to do? - ANS-Assist the patient to soak for 10 minutes in a
warm bath and then apply the cream to slightly damp skin within 2 to 3 minutes after bathing
Which patients are at risk for pressure ulcers? - ANS--A middle-aged quadriplegic patient who
is alert and conversant
-A bedridden patient who is in the late stage of Alzheimer's
-A very overweight patient who must be assisted to move in the bed
-A thin patient who sits for longer period and refuses meals
The nurse is caring for an obese patient who has been on bedrest for several days. The nurse
observes that the patient is beginning to develop redness on the sacral area. What intervention
is used to decrease the shearing force? - ANS-Place the patient in a side-lying position
The nurse is reviewing the results of a pressure mapping on patient at high risk for pressure
ulcers. The map shows a red area over the hips. How does the nurse interpret this evidence? -
ANS-Greater heat production associated with greater pressure
The nurse is assessing the nutritional status of a patient at risk for skin breakdown who has
been refusing to eat the hospital food. Which indicator is the most sensitive in identifying
inadequate nutrition for this patient? - ANS-Prealbumin level of 17.5 mg/dL
Seeing a reddened area on a patient's skin, the nurse presses firmly with fingers at the center of
the are and see that the area blanches with pressure. The nurse interprets this finding as
changes related to which factor? - ANS-Blood vessel dilation
The nurse is assessing a wound on a patient's abdomen. What is the correct technique? -
ANS-Assess the wound as a clock face with 12 o'clock towards the patient's head and 6 o'cock
towards the patient's feet
, The nurse is assessing a patient's wound every day for signs of healing or infection. Which
finding is a positive indication that healing is progressing as expected? - ANS-Area appears
pale pink, progressing to a spongy texture with a beefy red color
The nurse is irrigating a large pressure ulcer on a patient's hip, and notes a small opening in the
skin with purulent drainage. Which technique does the nurse use to check for tunneling? -
ANS-Use a sterile cotton-tipped applicator to probe gently for a tunnel
The nurse is assessing a patient's skin and notes a 2" x 2" purplish-colored area on the coccyx
with skin intact. These findings suggest which stage of a pressure ulcer? - ANS-Suspected
deep tissue injury
When developing a plan of care for a patient who is at high risk for skin breakdown, what does
the nurse include in the plan of care? - ANS--Applying a pressure reduction overlay to the
mattress
-Frequent repositioning of the patient
-Using positioning devices to keep heels pressure-free
Which expected outcome is most appropriate for a patient with a 1" x 1" stage II sacral
decubitus ulcer? - ANS-Wound will show granulation and decrease in size
A patient receiving negative pressure wound therapy (NPWT) should be monitored closely for
what potential complication? - ANS-Bleeding
Which class of medication would exclude a patient from participating in NPWT? -
ANS-Anticoagulants
A patient on the unit has herpes zoster. Which staff members would be the best to assign to the
care of this patient? - ANS-Staff members who have had chicken pox
A mother reports that her child has dry skin with itching that seems to worsen at night. What
nonpharmacologic interventions does the nurse teach to the mother? - ANS--Keep the child's
fingernails short and filed to reduce skin damage
-Place mittens or splints on the child's hands at night if the scratching is causing skin tears
-Read the child a relaxing and familiar story to reduce stress
The health care provider recommended over-the-counter Benadryl to treat the patient's hives.
What does the nurse suggest to the patient for self-care? - ANS-Avoid alcohol consumption,
which can potentiate the sedative effect of Benadryl
In order to assist the health care provider in determining if avoidance therapy is appropriate for
the patient, which question would the nurse ask? - ANS-Have you used any new soaps,
detergents, or personal care products?
Questions
The nurse sees in the patient's record that the patient has a Braden score of 20. Which nursing
action is the nurse most likely to perform in the care of this patient? - ANS-Continue routine
assessments
A thin, malnourished patient requires emergency abdominal surgery. After the surgery, in order
to promote wound healing, what does the nurse encourage? - ANS-High-quality protein diet
The nurse is directing the home health unlicensed assistive personnel (UAP) in the care of an
older adult patient. The patient reports dry skin and wants help in applying an emollient cream.
What does the nurse direct the UAP to do? - ANS-Assist the patient to soak for 10 minutes in a
warm bath and then apply the cream to slightly damp skin within 2 to 3 minutes after bathing
Which patients are at risk for pressure ulcers? - ANS--A middle-aged quadriplegic patient who
is alert and conversant
-A bedridden patient who is in the late stage of Alzheimer's
-A very overweight patient who must be assisted to move in the bed
-A thin patient who sits for longer period and refuses meals
The nurse is caring for an obese patient who has been on bedrest for several days. The nurse
observes that the patient is beginning to develop redness on the sacral area. What intervention
is used to decrease the shearing force? - ANS-Place the patient in a side-lying position
The nurse is reviewing the results of a pressure mapping on patient at high risk for pressure
ulcers. The map shows a red area over the hips. How does the nurse interpret this evidence? -
ANS-Greater heat production associated with greater pressure
The nurse is assessing the nutritional status of a patient at risk for skin breakdown who has
been refusing to eat the hospital food. Which indicator is the most sensitive in identifying
inadequate nutrition for this patient? - ANS-Prealbumin level of 17.5 mg/dL
Seeing a reddened area on a patient's skin, the nurse presses firmly with fingers at the center of
the are and see that the area blanches with pressure. The nurse interprets this finding as
changes related to which factor? - ANS-Blood vessel dilation
The nurse is assessing a wound on a patient's abdomen. What is the correct technique? -
ANS-Assess the wound as a clock face with 12 o'clock towards the patient's head and 6 o'cock
towards the patient's feet
, The nurse is assessing a patient's wound every day for signs of healing or infection. Which
finding is a positive indication that healing is progressing as expected? - ANS-Area appears
pale pink, progressing to a spongy texture with a beefy red color
The nurse is irrigating a large pressure ulcer on a patient's hip, and notes a small opening in the
skin with purulent drainage. Which technique does the nurse use to check for tunneling? -
ANS-Use a sterile cotton-tipped applicator to probe gently for a tunnel
The nurse is assessing a patient's skin and notes a 2" x 2" purplish-colored area on the coccyx
with skin intact. These findings suggest which stage of a pressure ulcer? - ANS-Suspected
deep tissue injury
When developing a plan of care for a patient who is at high risk for skin breakdown, what does
the nurse include in the plan of care? - ANS--Applying a pressure reduction overlay to the
mattress
-Frequent repositioning of the patient
-Using positioning devices to keep heels pressure-free
Which expected outcome is most appropriate for a patient with a 1" x 1" stage II sacral
decubitus ulcer? - ANS-Wound will show granulation and decrease in size
A patient receiving negative pressure wound therapy (NPWT) should be monitored closely for
what potential complication? - ANS-Bleeding
Which class of medication would exclude a patient from participating in NPWT? -
ANS-Anticoagulants
A patient on the unit has herpes zoster. Which staff members would be the best to assign to the
care of this patient? - ANS-Staff members who have had chicken pox
A mother reports that her child has dry skin with itching that seems to worsen at night. What
nonpharmacologic interventions does the nurse teach to the mother? - ANS--Keep the child's
fingernails short and filed to reduce skin damage
-Place mittens or splints on the child's hands at night if the scratching is causing skin tears
-Read the child a relaxing and familiar story to reduce stress
The health care provider recommended over-the-counter Benadryl to treat the patient's hives.
What does the nurse suggest to the patient for self-care? - ANS-Avoid alcohol consumption,
which can potentiate the sedative effect of Benadryl
In order to assist the health care provider in determining if avoidance therapy is appropriate for
the patient, which question would the nurse ask? - ANS-Have you used any new soaps,
detergents, or personal care products?
